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ISCHEMIC AND HYPOXIC INJURY

This is the most common type of cell injury in clinical medicine and has been studied
extensively in humans, in experimental animals, and in culture systems.
[27][28][29]
Reasonable
scenarios concerning the mechanisms underlying the morphologic changes have emerged.
Hypoxia refers to any state of reduced oxygen availability. It may be caused by reduced
amounts or saturation of hemoglobin. Ischemia, on the other hand, is brought about by
reduced blood flow, usually as a consequence of a mechanical obstruction in the arterial
system but sometimes as a result of a catastrophic fall in blood pressure or loss of blood. In
contrast to hypoxia, during which glycolytic energy production can continue, ischemia
compromises the delivery of substrates for glycolysis. Thus, in ischemic tissues, anaerobic
energy generation stops after glycolytic substrates are exhausted, or glycolytic function
becomes inhibited by the accumulation of metabolites that would have been removed
otherwise by blood flow. For this reason, ischemia tends to injure tissues faster than does
hypoxia.
Types of Ischemic Injury.
Ischemic injury is the most common clinical expression of cell injury by oxygen deprivation.
The most useful models for studying ischemic injury involve complete occlusion of one of the
end-arteries to an organ (e.g., a coronary artery) and examination of the tissue (e.g., cardiac
muscle) in areas supplied by the artery. Complex pathologic changes occur in diverse cellular
systems during ischemia. Up to a certain point, for a duration that varies among different
types of cells, the injury is amenable to repair, and the affected cells can recover if oxygen and
metabolic substrates are again made available by restoration of blood flow. With further
extension of the ischemic duration, cell structure continues to deteriorate, owing to relentless
progression of ongoing injury mechanisms. With time, the energetic machinery of the cellthe
mitochondrial oxidative powerhouse and the glycolytic pathwaybecomes irreparably
damaged, and restoration of blood flow (reperfusion) cannot rescue the damaged cell. Even
if the cellular energetic machinery were to remain intact, irreparable damage to the genome or
to cellular membranes will ensure a lethal outcome regardless of reperfusion. This
irreversible injury is usually manifested as necrosis, but apoptosis may also play a role.
Under certain circumstances, when blood flow is restored to cells that have been previously
made ischemic but have not died, injury is often paradoxically exacerbated and proceeds at
an accelerated pace. As a consequence, reperfused tissues may sustain loss of cells in
addition to cells that are irreversibly damaged at the end of ischemia. This is a clinically
important process that contributes to net tissue damage during myocardial and cerebral
infarction, as described in Chapter 12 and Chapter 28 . This so-called ischemia-reperfusion
injury (discussed later) is particularly significant because appropriate medical treatment can
decrease the fraction of cells that may otherwise be destined to die in the "area at risk."
Mechanisms of Ischemic Cell Injury.
The sequence of events following hypoxia was described earlier and is summarized in Figure
1-22 .
[28][29]
Briefly, as the oxygen tension within the cell decreases, there is loss of oxidative
phosphorylation and decreased generation of ATP. The depletion of ATP results in failure of
the sodium pump, with loss of potassium, influx of sodium and water, and cell swelling. There
is progressive loss of glycogen and decreased protein synthesis. There may be severe
functional consequences at this stage. For instance, heart muscle ceases to contract within 60
seconds of coronary occlusion. Note, however, that loss of contractility does not mean cell
death. If hypoxia continues, worsening ATP depletion causes further morphologic
deterioration. The cytoskeleton disperses, resulting in the loss of ultrastructural features such
as microvilli and the formation of "blebs" at the cell surface (see Fig. 1-17 ). "Myelin figures,"
derived from plasma as well as organellar membranes, may be seen within the cytoplasm or
extracellularly. They are thought to result from dissociation of lipoproteins with unmasking of
phosphatide groups, promoting the uptake and intercalation of water between the lamellar
stacks of membranes. At this time, the mitochondria are usually swollen, owing to loss of
volume control by these organelles; the endoplasmic reticulum remains dilated; and the entire
cell is markedly swollen, with increased concentrations of water, sodium, and chloride and a
decreased concentration of potassium. If oxygen is restored, all of these disturbances are
reversible.


Figure 1-22 Postulated sequence of events in reversible and irreversible ischemic cell injury.
Note that although reduced oxidative phosphorylation and ATP levels have a central role,
ischemia can cause direct membrane damage. ER, endoplasmic reticulum; CK, creatine
kinase; LDH, lactate dehydrogenase; RNP, ribonucleoprotein.


If ischemia persists, irreversible injury and necrosis ensue. Irreversible injury is associated
morphologically with severe swelling of mitochondria, extensive damage to plasma
membranes, and swelling of lysosomes (see Fig. 1-17C ). Large, flocculent, amorphous
densities develop in the mitochondrial matrix. In the myocardium, these are indications of
irreversible injury and can be seen as early as 30 to 40 minutes after ischemia. Massive influx
of calcium into the cell then occurs, particularly if the ischemic zone is reperfused. Death is
mainly by necrosis, but apoptosis also contributes; the apoptotic pathway is activated probably
by release of proapoptotic molecules from leaky mitochondria. After death, cell components
are progressively degraded, and there is widespread leakage of cellular enzymes into the
extracellular space and, conversely, entry of extracellular macromolecules from the interstitial
space into the dying cells. Finally, the dead cell may become replaced by large masses
composed of phospholipids in the form of myelin figures. These are then either phagocytosed
by other cells or degraded further into fatty acids. Calcification of such fatty acid residues may
occur with the formation of calcium soaps.
As we mentioned previously, leakage of intracellular enzymes and other proteins across the
abnormally permeable plasma membrane and into the plasma provides important clinical
parameters of cell death. For example, elevated serum levels of cardiac muscle creatine
kinase MB and troponin are valuable clinical indicators of myocardial infarction, an area of cell
death in heart muscle ( Chapter 12 ).
ISCHEMIA-REPERFUSION INJURY
Restoration of blood flow to ischemic tissues can result in recovery of cells if they are
reversibly injured, or not affect the outcome if irreversible cell damage has occurred. However,
depending on the intensity and duration of the ischemic insult, variable numbers of cells may
proceed to die after blood flow resumes, by necrosis as well as by apoptosis.
[30]
The affected
tissues often show neutrophilic infiltrates. As noted earlier, this ischemia-reperfusion injury is a
clinically important process in such conditions as myocardial infarction and stroke and may be
amenable to therapeutic interventions.
How does reperfusion injury occur? The likely answer is that new damaging processes are
set in motion during reperfusion, causing the death of cells that might have recovered
otherwise.
[31][32]
Several mechanisms have been proposed:

? New damage may be initiated during reoxygenation by increased generation of oxygen free
radicals from parenchymal and endothelial cells and from infiltrating leukocytes.
[31][33]

Superoxide anions can be produced in reperfused tissue as a result of incomplete and
vicarious reduction of oxygen by damaged mitochondria or because of the action of oxidases
derived from leukocytes, endothelial cells, or parenchymal cells.
[32]
Cellular antioxidant
defense mechanisms may also be compromised by ischemia, favoring the accumulation of
radicals. Free radical scavengers may be of therapeutic benefit.

? Reactive oxygen species can further promote the mitochondrial permeability transition,
referred to earlier, which, when it occurs, precludes mitochondrial energization and cellular
ATP recovery and leads to cell death.
[25]


? Ischemic injury is associated with inflammation as a result of the production of cytokines and
increased expression of adhesion molecules by hypoxic parenchymal and endothelial
cells.
[31][33]
These agents recruit circulating polymorphonuclear leukocytes to reperfused
tissue; the ensuing inflammation causes additional injury ( Chapter 2 ). The importance of
neutrophil influx in reperfusion injury has been demonstrated by experimental studies that
have used anti-inflammatory interventions, such as antibodies to cytokines or adhesion
molecules, to reduce the extent of the injury.
[30][32]


? Recent data suggest that activation of the complement pathway may contribute to
ischemia-reperfusion injury.
[34]
The complement system is involved in host defense and is an
important mechanism of immune injury ( Chapter 6 ). Some IgM antibodies have a propensity
to deposit in ischemic tissues, for unknown reasons, and when blood flow is resumed,
complement proteins bind to the antibodies, are activated, and cause cell injury and
inflammation. Knockout mice lacking several complement proteins are resistant to this type of
injury.
[35]

CHEMICAL INJURY
The mechanisms by which chemicals, certain drugs, and toxins produce injury are described
in greater detail in Chapter 9 in the discussion of environmental disease. Here we will describe
two forms of chemically induced injury as examples of the sequence of events leading to cell
death.
Chemicals induce cell injury by one of two general mechanisms:
[36]


? Some chemicals can act directly by combining with some critical molecular component or
cellular organelle. For example, in mercuric chloride poisoning, mercury binds to the sulfhydryl
groups of the cell membrane and other proteins, causing increased membrane permeability
and inhibition of ATPase-dependent transport. In such instances, the greatest damage is
usually to the cells that use, absorb, excrete, or concentrate the chemicals in the case of
mercuric chloride, the cells of the gastrointestinal tract and kidney ( Chapter 9 ). Cyanide
poisons mitochondrial cytochrome oxidase and blocks oxidative phosphorylation. Many
antineoplastic chemotherapeutic agents and antibiotic drugs who induce cell damage by direct
cytotoxic effects.

? Most other chemicals are not biologically active but must be converted to reactive toxic
metabolites, which then act on target cells. This modification is usually accomplished by the
P-450 mixed function oxidases in the smooth endoplasmic reticulum of the liver and other
organs.
[37][38]
Although these metabolites might cause membrane damage and cell injury by
direct covalent binding to membrane protein and lipids, by far the most important mechanism
of membrane injury involves the information of reactive free radicals and subsequent lipid
peroxidation.
The diverse mechanisms of chemical injury are well illustrated by carbon tetrachloride and
acetaminophen. Carbon tetrachloride (CCl
4
) was once used widely in the dry-cleaning
industry.
[39]
The toxic effect of CCl
4
is due to its conversion by P-450 to the highly reactive
toxic free radical CCl
3
(CCl
4
+ e ? CCl
3
+ Cl
-
) ( Fig. 1-23 ). The free radicals produced locally
cause autooxidation of the polyenoic fatty acids present within the membrane phospholipids.
There, oxidative decomposition of the lipid is initiated, and organic peroxides are formed after
reacting with oxygen (lipid peroxidation). This reaction is autocatalytic in that new radicals are
formed from the peroxide radicals themselves. Thus, rapid breakdown of the structure and
function of the endoplasmic reticulum is due to decomposition of the lipid. It is no surprise,
therefore, that CCl
4
-induced liver cell injury is both severe and extremely rapid in onset. Within
less than 30 minutes, there is a decline in hepatic protein synthesis; within 2 hours, there is
swelling of smooth endoplasmic reticulum and dissociation of ribosomes from the rough
endoplasmic reticulum. Lipid export from the hepatocytes is reduced owing to their inability to
synthesize apoprotein to complex with triglycerides and thereby facilitate lipoprotein secretion.
The result is the fatty liver of CCl
4
poisoning ( Fig. 1-24 ). (Fatty liver is discussed later in the
chapter.) Mitochondrial injury then occurs, and this is followed by progressive swelling of the
cells due to increased permeability of the plasma membrane. Plasma membrane damage is
through to be caused by relatively stable fatty aldehydes, which are produced by lipid
peroxidation in the smooth endoplasmic reticulum but are able to act at distant sites. This is
followed by massive influx of calcium and cell death (see Fig. 1-23 ).


Figure 1-23 Sequence of events leading to fatty change and cell necrosis in carbon
tetrachloride (CCl
4
) toxicity. RER, rough endoplasmic reticulum; SER, smooth endoplasmic
reticulum.



Figure 1-24 Rat liver cell 4 hours after carbon tetrachloride intoxication, with swelling of
endoplasmic reticulum and shedding of ribosomes. At this stage, mitochondria are
unaltered. (Courtesy of Dr. O. Iseri, University of Maryland, Baltimore, MD.)



Acetaminophen (Tylenol), a commonly used analgesic drug, is detoxified in the liver through
sulfation and glucuronidation, and small amounts are converted by cytochrome
P-450-catalyzed oxidation to an electrophilic, highly toxic metabolite.
[40]
This metabolite itself
is detoxified by interaction with GSH. When large doses of the drug are ingested, GSH is
depleted, and thus the toxic metabolites accumulate in the cell, destroy nucleophilic
macromolecules, and covalently bind proteins and nucleic acids. The decrease in GSH
concentration, coupled with covalent binding of toxic metabolites, increases drug toxicity,
resulting in massive liver cell necrosis, usually 3 to 5 days after the ingestion of toxic doses.
This hepatotoxicity correlates with lipid peroxidation and can be reduced by administration of
antioxidants, suggesting that the oxidative damage may be more important than covalent
binding in the ultimate toxicity of the drug.
[41]

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